Bigger Postpartum Challenges Than Just Baby Weight

Pregnancy Can Put Significant Strain on Muscles and Bones

Having a baby leaves a woman's body off kilter in various ways that are often overlooked. Sarah Nassauer and physical therapist Marianne Ryan join Lunch Break with a look at what women should (and shouldn't) be doing. Photo: AP.

The issue of baby weight hangs heavy on the minds of many postpartum women, with images of famous moms like the impossibly fit model Gisele Bündchen, who had her second child last year, seared into their brains.

But more women and health professionals are turning their attention to changes beyond weight. Pregnancy and labor cause significant strain on muscle and bone structures. Some research shows that stretched, weakened or torn muscles and misaligned bones may seem simply annoying at first, but can develop into debilitating disorders years or decades later.

More women in the U.S. are having babies older and in some cases spacing pregnancies closer together, giving the body less time to recover. There has also been an increase in fertility treatments such as in vitro fertilization, which lead to more twin pregnancies that add to the physical strain on women's bodies.

"It's a massive physical challenge" to have a baby, says Jessica McKinney, director of the Center for Pelvic and Women's Health at Marathon Physical Therapy and Sports Medicine based in Boston. Abdominal muscles lengthen significantly during pregnancy, the spine moves into an exaggerated S curve, caesarean section can leave internal scar tissue, and the hammock of muscles in the pelvis that support organs and bones, called the pelvic floor, stretches or even tears, she says.

Before and After Baby

Left untreated, the changes can cause problems down the road, from pelvic and low back pain to incontinence and other issues.

Courtney Freck, an avid runner who lives in Sterling, Va., started having sharp hip and back pain while running about a year after the c-section birth of her second daughter. Doctors weren't sure what was wrong. Eventually, she consulted a women's health physical therapist who pointed to her weak core muscles and her lingering diastasis recti, or the separation of her "six-pack" muscles. The separation occurs in almost all pregnancies and often doesn't resolve on its own.

"I just thought it was one of those things, you have a baby and things never go back," says the 36-year-old purchasing manager for a health-care company. She did exercises to strengthen her interior abdominal muscles and pelvic floor. She is now training for a marathon, running about 25 miles a week.

ENLARGE

To reduce diastasis recti during pregnancy, physical therapists recommend avoiding sit-up movements that rely on the external abdominal muscles. Instead, they suggest women get out of bed by lying on their sides and pushing themselves up with their arms.

With a new baby to care for, women often ignore seemingly small things like pain, says Ms. McKinney of Marathon Physical Therapy. Patients think "I have to throw myself at the altar of motherhood," and it's normal that my body doesn't work as well, she says.

To explain why so many of their patients don't seek treatment until years after they gave birth, many health professionals that focus on musculoskeletal issues during and after pregnancy tell a similar tale.

"I will hear, 'After my first pregnancy I occasionally leaked as I coughed' " or I had some pain, but I didn't see it as a problem, says Secili Destefano, a physical therapist and director of research for the American Physical Therapy Association Section on Women's Health. Then a woman ages, her muscles start to deteriorate and her hormone levels change. "And now your body is doing things you don't want it to," she says, and finally you go to a doctor.

If a woman seeks help earlier "we can use simpler treatments," such as physical therapy in lieu of surgery to repair a weakened pelvic floor or pelvic organ prolapse, says Linda Brubaker, an urogynecologist and dean of the Stritch School of Medicine at Loyola University Chicago.

Dr. Brubaker recommends every woman ask her doctor or nurse to check her pelvic floor strength at the 4-to-6-week postpartum checkup. The pelvic floor is "the center of the universe," because it supports so many organs and bones, she says.

Even c-section scarring can be treated to prevent pain. Any internal scar can adhere to other parts of the body while healing, hampering muscle movement or causing pain years later, says Debra Goodman, a physical therapist in Albany, N.Y. She massages scar tissue once it has healed to keep skin and tissue mobile, she says, noting improvement can happen "even 20 years later." About 30% of births happen via c-section in the U.S.

Women are regularly told by doctors to do Kegel exercises to strengthen the pelvic floor during or after pregnancy, but many women do them incorrectly, pushing out instead of up and in or contracting the wrong muscles, says Colleen Fitzgerald, medical director of the Chronic Pelvic Pain Program at Loyola University Chicago.

Many of these issues get little attention among women and some obstetricians for a complex web of reasons. A spokesman for the American Congress of Obstetricians and Gynecologists says there is a "tremendous amount of information that must be conveyed" at a postpartum visit and that doctors refer patients to specialists when they find problems with the pelvic floor. Obstetricians rely on prenatal classes to train patients in Kegel exercises, he said.

Exercising too hard too soon can lead to problems including pelvic pain, say some doctors and physical therapists. Women can exercise as they normally would during pregnancy and after their 4-to-6-week postpartum checkup as long as they don't have pain, say most health professionals.

If a postpartum woman has weak core muscles or a large diastasis recti, running or other pounding exercises can be problematic. Hold off until you know you have stable core strength, says Marianne Ryan, owner of MRPT Physical Therapy in New York City. However, women can start doing pelvic floor and breathing exercises in the days following labor if it doesn't cause pain, says Ms. Ryan.

Symptoms that are often linked to unresolved injuries during childbirth are common in the U.S., especially as women age. Almost 40% of women 60 to 79 years old report symptoms of some type of pelvic floor disorder, which includes incontinence and pelvic organ prolapse, when organs press against or descend into the vaginal walls causing a sensation of pressure, according to a 2008 study from the Journal of the American Medical Association.

In the study, the more children a woman gave birth to the more likely she was to have symptoms. Overall about 24% of U.S. women who aren't currently pregnant had such symptoms, according to the study that reviewed medical data for 1961 women 20 and older. Obesity was also a risk factor. Some research shows these numbers are likely to increase in the coming decades as the population ages.

"I felt really accomplished that I had good pregnancies," says Karen Ivas, a 56-year-old Mansfield, Mass., resident and mother of five. "A week after I delivered I was in my jeans."

But in her early 50s she started to experience minor incontinence issues. "I didn't think too much of it," says Ms. Ivas, until she realized she couldn't live "without having to worry about where the next bathroom was."

One doctor she consulted said, "Oh that's the way it is. A lot of people have your problem," she says. She had surgery to lift her uterus and other repairs, but it didn't resolve her problem, she says. More recently she has found some relief from regular trips to a women's health physical therapist, doing hands-on therapy and other exercises.

"I had more than one OB and nobody ever said anything to me about pelvic health," she says.

The Supreme Court ruled that 14 year old single girls have the right to privacy when pregnant. The kid may look pregnant to a teacher but the teacher nor any other school administrator can inform the parent. If there is a miscarriage in school you call an ambulance and inform the parent the child had a medical problem and is in the hospital.

Today Catholic Republicans want to defund Obamacare - after all the more unwanted kids ... I can only take the lead from nuns in Spain told single mothers their babies died, and sold them ... you can see where I'm going, but then I wonder why these pregnant girls are not allowed in a parochial school ... when millions can be made ... from the right to privacy ... but then some would be willing to share their secret.

“Pregnancy and labor cause significant strain on muscle and bone structures. Some research shows that stretched, weakened or torn muscles and misaligned bones may seem simply annoying at first, but can develop into debilitating disorders years or decades later.”

“One doctor she consulted said, "Oh that's the way it is. A lot of people have your problem," she says. She had surgery to lift her uterus and other repairs, but it didn't resolve her problem, she says. More recently she has found some relief from regular trips to a women's health physical therapist, doing hands-on therapy and other exercises.”

From an Eastern medicine perspective, one of the of the additional health issues that you will expect to see is that as the physical pain and misalignment of the body persists, the person will start to adjust their posture, gait and muscles to compensate. The resulting strain towards particular joints and muscles will accelerate the body getting further out of balance and lead eventually to organ-related diseases.

The person will have to choose to either invest now in the time and energy to naturally make the body stronger from the inside out or later rely on medication and surgeries to try and alleviate the problems.

Very important for women. My mother began to experience very minor bladder issues after my younger brother was born and, because she was reluctant to undergo surgery, just ignored it. Forty years later, when the incontinence was becoming a bigger problem, she had surgery to correct the prolapsed bladder, but because the muscles and ligaments had stretched so much, the elasticity was gone, and the surgery was unsuccessful. At the age of 85, she had to have a full hysterectomy, and even then the problem wasn't solved because of the stretched muscles.

Women--don't ignore any symptoms after childbirth; get medical attention.

Kudos to the WSJ for covering this major health issue that surely has plagued women ever since we became bipeds. Interesting to look at a late-1800s Sears or Montgomery Ward catalog reproduction -- you will see all manner of devices such as pessaries sold to women to address pelvic organ prolapse. Heck of a way to live. Prevention through education on safe posture, safe exercise (situps = NO) and safe lifting is hugely important and should start in the teens. We can minimize damage and strengthen muscles -- but no amount of exercise will fix support ligaments once they are stretched or broken.

What a crock! Millions of women have children without these so called invented health problems. Our mothers and grandmothers never complained about how having children affected their lives. In the 3rd world the women have it much tougher and yet aren't complaining. Americans enjoy such prosperity and wellness that we now have invented a new class of victims, all due to the wonderful gift of life. Gee, what else can we start complaining about?

Brian -- From a treatment point of view, it actually helps to have a clear understanding of the processes involved and which muscles, tendons, ligaments, etc. are affected and in what specific ways. Then you can begin to design interventions that will help.

About 10% of women died of maternity complications before modern medical obstetrics. Women in the "third world" aren't complaining because they're poor, malnourished, abused, and eventually die long before they need to.

Please don't romanticize childbirth of the past. Even if women did survive birth and the postpartum period without childbed fever or hemorrhage, there were no reliable surgical remedies for many of the long-term problems this article describes. Nor can I imagine what such surgery as there would would have been like without anesthesia.

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